Practice Questions

A nurse is about to inject RhoGAM into an Rh-negative mother. Which of the following is the preferred site for the injection? 1. Deltoid.2. Dorsogluteal. 3. Vastus lateralis. 4. Ventrogluteal.

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A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which hormone? 1. progesterone 2. estrogen 3. somatotropin 4. aldosterone

2. Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotropin production. Hyperemesis is also associated with infectious conditions, such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole. Progesterone is 210 a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone.

A nurse who is caring for a pregnant diabetic should carefully monitor the client for which of the following? 1. Urinary tract infection.2. Multiple gestation.3. Metabolic alkalosis.4. Pathological hypotension.

1.

A pregnant diabetic has been diagnosed with hydramnios. Which of the following would explain this finding? 1. Excessive fetal urination.2. Recurring hypoglycemic episodes. 3. Fetal sacral agenesis.4. Placental vascular damage.

1. The majority of amni- otic fluid is created as urine by the fetal kidneys. Fetuses of diabetic mothers of- ten experience polyuria as a result of hy- perglycemia. If the mother's diabetes is out of control, excess glucose diffuses across the placental membrane, resulting in the fetus becoming hyperglycemic. As a result the fetus exhibits the classic sign of diabetes—polyuria. If the mother's serum glucose levels are very high during the first trimester, it is likely that the fe- tus will develop structural congenital de- fects. Sacral agenesis is one of the most severe of these defects.

A client with 4 protein and 4 reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1. A client who is diag- nosed with severe preeclampsia is high risk for becoming eclamptic. Clients who become eclamptic have had at least one seizure.

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which type of diet should the nurse discuss? 1. high-residue diet 2. low-sodium diet 3. regular diet 4. high-protein diet

3. For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which action should the nurse take first? 1. Insert an airway to improve oxygenation. 2. Note the time when the seizure begins and ends. 3. Call for immediate assistance. 4. Turn the client to her left side.

3. Principles of emergency management begin with calling for assistance. If a client begins to have a seizure, the first action by the nurse is to remain with the client and call for immediate assistance. The nurse needs to have some assistance in managing this client. After the seizure, the client needs intensive monitoring. An airway can be inserted, if appropriate, after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side should be done after assistance is obtained.

A woman, 8 weeks pregnant, is admitted to the obstetric unit with a diagnosis of threatened abortion. Which of the following tests would help to determine whether the woman is carrying a viable or a nonviable pregnancy? 1. Luteinizing hormone level. 2. Endometrial biopsy.3. Hysterosalpinogram.4. Serum progesterone level.

4. When a previously gravid client is seen by her health care practitioner with a complaint of vaginal bleeding, it is very important to deter- mine the viability of the pregnancy as soon as possible. Situational crises are often exacerbated when clients face the unknown. One relatively easy way to de- termine the viability of the conceptus is by performing a serum progesterone test; high levels indicate a viable baby while low levels indicate a pregnancy loss. Ultrasonography to assess for a beating heart may also be performed.

A type 1 diabetic is being seen for preconception counseling. The nurse should emphasize that during the first trimester the woman may experience which of the following? 1. Need for less insulin than she normally injects. 2. An increased risk for hyperglycemic episodes. 3. Signs and symptoms of hydramnios.4. A need to be hospitalized for fetal testing.

1. Nausea and vomiting are common complaints of gravid clients during the first trimester. As a result, women, including diabetic women, con- sume fewer calories than before becom- ing pregnant. Their need for insulin drops commensurately. Therefore, it is very important that the women monitor their blood glucose regularly upon awak- ening and throughout the day.

99. The nurse performs a routine prenatal assessment on a woman at 35 weeks' gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1°F (37.3°C). Which statement is most appropriate for the nurse to make at this time? 1. "Your pulse is low. Do you exercise a lot?" 2. "Your blood pressure is slightly high. I will check it again before you leave." 3. "You have a slight temperature. Do you feel hot?" 4. "Your vital signs are all normal. I will document them on your medical record.

2. A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing "white coat" syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vitals are within normal range.

An obese gravid woman is being seen in the prenatal clinic. The nurse will monitor this client carefully throughout her pregnancy because she is high risk for which of the following complications of pregnancy? 1. Placenta previa.2. Gestational diabetes. 3. Abruptio placentae.4. Chromosomal defects.

2. Because clients who enter pregnancy obese are at such high risk for gestational diabetes, many obste- tricians skip the glucose challenge test and automatically schedule a glucose tolerance test at approximately 24 weeks' gestation. As a result, the complication is discovered much earlier and intervention can begin much earlier.

A 12-week-gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. What should the nurse assess this client for? 1. Shortness of breath.2. Enlarging abdominal girth. 3. Hyperreflexia and clonus. 4. Fetal heart dysrhythmias.

4. It is essential that the test taker carefully read the weeks of gestation when answering this question. If the client were in the third trimester, it would be appropriate to check the fetal heart as well as to monitor for increasing abdominal girth measurements. At 12 weeks, however, the latter assessment is not appropriate.

When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which therapeutic agent would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation (DIC)? 1. Ringer's lactate solution 2. fresh frozen platelets 3. 5% dextrose solution 4. warfarin

2. Treatment of DIC includes treating the causative factor, replacing maternal coagulation factors, and supporting physiologic functions. Intravenous infusions of whole blood, fresh frozen plasma, or platelets are used to replace depleted maternal coagulation factors. Although Ringer's lactate solution and 5% dextrose solution may be used as intravenous fluid replacement, the client needs blood component therapy. Therefore, normal saline must be used. Intravenous heparin, not warfarin, may be administered to halt the clotting cascade.

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider (HCP) because the nurse suspects which sexually transmitted infection? 1. gonorrhea 2. Chlamydia trachomatis infection 3. syphilis 4. herpes genitalis

4. The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. trachomatis infection in women is commonly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre.

Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? 1. 30-week gestation with prolapsed mitral valve (PMV). 2. 32-week gestation with urinary tract infection (UTI). 3. 34-week gestation with gestational diabetes (GDM). 4. 36-week gestation with deep vein thrombosis (DVT).

2. Although the exact mechanism is not well understood, clients who have urinary tract infections are high risk for PPROM. This is partic- ularly important since pregnant clients often have urinary tract infections that present either with no symptoms at all or only with urinary frequency, a complaint of many pregnant clients.

Which statement by the client indicates an understanding of the teaching regarding of the use of corticosteroids during preterm labor? 1. "I will be taking corticosteroids until my baby's due date so that he or she will have the best chance of doing well." 2. "The corticosteroids may help my baby's lungs mature." 3. "The goal of the corticosteroids is to stop contractions and help me get to my due date." 4. "If I take corticosteroids, my baby will not have to spend any time in the neonatal intensive care unit when he or she is born."

2. Corticosteroids given IM have been shown to increase fetal lung maturity by increasing surfactant and reduce the risk of respiratory distress syndrome in premature infants. It is not a guarantee that a premature newborn would not have problems at birth that would require time in the neonatal intensive care unit. The administration of the corticosteroids is normally completed within 24 to 48 hours.

The primary healthcare provider (HCP) prescribes intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which medication would be most important for the nurse to have readily available? 1. diazepam 2. hydralazine 3. calcium gluconate 4. phenytoin

3. The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam is used to treat anxiety, and usually it is not given to pregnant women. Hydralazine would be used to treat hypertension, and phenytoin would be used to treat seizures.

A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which will occur regarding the client's insulin needs during the first trimester? 1. They will increase. 2. They will decrease. 3. They will remain constant. 4. They will be unpredictable.

2. During the first trimester, it is not unusual for insulin needs to decrease, commonly as a result of nausea and vomiting. Progressive insulin resistance is characteristic of pregnancy, particularly in the second half of pregnancy. It is not unusual for insulin needs to increase by as much as four times the nonpregnant dose after about the 24th week of gestation. This resistance is caused by the production of human placental lactogen, also called human chorionic somatotropin, by the placenta and by other hormones, such as estrogen and progesterone, which are insulin antagonists.

92. Which diagnostic test would be the most important for a 40-yearold primigravid client to have in the second trimester of her pregnancy? 1. beta strep screening 2. chorionic villus sampling 3. ultrasound testing 4. quad screen

4. A maternal quad screen testing is done to screen for genetic and neural tube abnormalities between the 15th and 18th weeks of gestation. The four tests included are an alpha fetoprotein (AFP), human chorionic gonadotropin, estriol, and inhibin-A. Abnormally high levels of AFP found in maternal serum may be indicative of neural tube defects such as anencephaly and spina bifida. Low levels may indicate trisomy 21 (Down syndrome). Beta strep testing is done in the third trimester. Chorionic villus sampling is done as early as 10 weeks' gestation to detect anomalies. Ultrasound testing may be done in the first trimester to determine fetal viability and in the third trimester to determine pelvic adequacy and fetal or placental position. CN: Reduction

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? 1. applying external fetal monitor and completing a physical assessment 2. applying external fetal monitor and performing a sterile vaginal exam 3. obtaining a fundal height physical assessment on the client 4. obtaining fundal height and a sterile vaginal exam

1. Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which symptom would most likely alert the nurse that placenta previa is present? 1. painless vaginal bleeding 2. uterine tetany 3. intermittent pain with spotting 4. dull lower back pain

1. The most common assessment finding associated with placenta previa is painless vaginal bleeding. With placenta previa, the placenta is abnormally implanted, covering a portion or all of the cervical os. Uterine tetany, intermittent pain with spotting, and dull lower back pain are not associated with placenta previa. Uterine tetany is associated with oxytocin administration. Intermittent pain with spotting commonly is associated with a spontaneous abortion. Dull lower back pain is commonly associated with poor maternal posture or a urinary tract infection with renal involvement.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment finding would alert the nurse to suspect hypermagnesemia? 1. decreased deep tendon reflexes 2. cool skin temperature 3. rapid pulse rate 4. tingling in the toes

1. Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse to say she has had a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client: 1. "Take two acetaminophen tablets. They are not as likely to upset your stomach." 2. "I think the healthcare provider should see you today. Can you come to the clinic this morning?" 3. "You need to lie down and rest. Have you tried placing a cool compress over your head?" 4. "I will ask the healthcare provider to call in a prescription for nausea medications. What is your pharmacy's number?"

2. A client with preeclampsia and a continuous headache for 2 days should be seen by a healthcare provider (HCP) immediately. Continuous headache, drowsiness, and mental confusion indicate poor cerebral perfusion and are symptoms of severe preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Treatment for nausea may be indicated but only after the primary care primary provider has seen the client and determined if the preeclampsia requires further treatment.

The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year history of insulin-dependent diabetes. Which complication, if stated by the client, indicates the need for additional teaching? 1. Candida albicans infection 2. twin-to-twin transfusion 3. polyhydramnios 4. preeclampsia

2. Clients who are pregnant and have diabetes are not at greater risk for multifetal pregnancy and subsequent twin-to-twin transfusion unless they have undergone fertility treatments. The pregnant diabetic client is at higher risk for complications such as infection, polyhydramnios, ketoacidosis, and preeclampsia, compared with the pregnant nondiabetic client.

The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the healthcare provider (HCP)? 1. activated partial thromboplastin time (APTT) of 30 seconds 2. hemoglobin of 11.5 g/dL (115 g/L) 3. urinary output of 25 mL in the past hour 4. platelets at 149,000/mm3 (149 × 109/L)

3. Urinary output of less than 30 mL/h indicates renal compromise and would be the most important assessment finding to report to the HCP . The APTT is within normal limits, and the hemoglobin is lower than values for an adult female but within normal limits for a pregnant female. Although the platelet level is slightly low and may impact blood clotting, when compared to renal failure, it is less important.

A laboring client at −2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. The nurse should first: 1. place gentle pressure upward on the fetal head. 2. place the cord back into the vagina to keep it moist. 3. begin oxygen by face mask at 8 to 10 L/min. 4. turn the client on her left side.

1. The nurse should place a hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother, but until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes to increase perfusion to the infant by relieving cord compression.

A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's: 1. red blood cell count. 2. degree of discomfort. 3. urinary output. 4. temperature.

4. Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.

98. A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week, and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? 1. abruptio placentae 2. HELLP syndrome 3. disseminated intravascular coagulation 4. threatened abortion

3. A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for abruptio placentae such as sharp pain and "woody," firm consistency of the abdomen. HELLP syndrome is a complication of preeclampsia that does not occur before 20 weeks' gestation unless a molar pregnancy is present. There is no evidence that she is threatening to abort as she has no cramping or vaginal bleeding.

When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? 1. oxytocin infusion solution 2. disposable tongue blades 3. portable ultrasound machine 4. padding for the side rails

4. The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the healthcare provider (HCP) concerning fetal movement? 1. "if the fetus is becoming less active than before" 2. "if it takes longer each day for the fetus to move 10 times" 3. "if the fetus stops moving for 12 hours" 4. "if the fetus moves more often than three times an hour"

4. The fetus is considered well if it moves more often than three times in 1 hour. Daily fetal movement counting is part of all high-risk assessments and is a noninvasive, inexpensive method of monitoring fetal well-being. The HCP should be notified if there is a gradual slowing over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer.

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. What are desired outcomes of this therapy? Select all that apply. 1. temperature, 98°F (36.7°C); pulse, 72 beats/min; respiratory rate, 14 breaths/min 2. urinary output less than 30 mL/h 3. fetal heart rate with late decelerations 4. blood pressure of less than 140/90 mm Hg 5. deep tendon reflexes 2+ 6. magnesium level = 5.6 mg/dL (2.8 mmol/L)

1,5,6. The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromuscular transmissions and decreasing the amount of acetylcholine liberated. The primary goal of magnesium sulfate therapy is to prevent seizures. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be >12 respirations per minute(rpm). Rates at 12 rpm or lower are associated with respiratory depression and are seen with magnesium toxicity. Renal compromise is identified with a urinary output of less than 30 mL/h. A fetal heart rate that is maintained within the 112 to 160 range is desired without later or variable decelerations. While extreme elevations of blood pressure must be treated, achieving a normal pressure carries the risk of decreasing perfusion to the fetus. Deep tendon reflexes should not be diminished or exaggerated. The therapeutic magnesium sulfate level of 5 to 8 mg/dL (2.5 to 4 mmol/L) is to be maintained.

Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the primary healthcare provider (HCP) prescribes a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which assessment finding should the nurse report immediately? 1. respiratory rate of 12 breaths/min 2. patellar reflex of +2 3. blood pressure of 160/88 mm Hg 4. urinary output exceeding intake

1. A respiratory rate of 12 breaths/min suggests potential respiratory depression, an adverse effect of magnesium sulfate therapy. The medication must be stopped, and the HCP should be notified immediately. A patellar reflex of +2 is normal. Absence of a patellar reflex suggests magnesium toxicity. A blood pressure reading of 160/88 mm Hg would be a common finding in a client with severe preeclampsia. Urinary output exceeding intake is not likely in a client receiving intravenous magnesium sulfate. Oliguria is more common.

A client at 36 weeks' gestation begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for: 1. abruptio placentae. 2. transverse lie. 3. placenta accreta. 4. uterine atony.

1. After an eclamptic seizure, the client is at risk for abruptio placentae due to severe vasoconstriction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested by a board-like abdomen and an abnormal fetal heart rate tracing. Transverse lie or shoulder presentation, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus, placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fluid. Placenta accreta, a rare phenomenon, refers to a condition in which the placenta abnormally adheres to the uterine lining. Uterine atony, or relaxed uterus, may occur after childbirth, leading to postpartum hemorrhage.

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/min. Which medication would the nurse expect the primary healthcare provider (HCP) to prescribe? 1. intravenous penicillin 2. intravenous gentamicin sulfate 3. intramuscular betamethasone 4. intramuscular cefaclor

1. Because group B streptococcus is a gram-positive bacterium, the HCP probably will prescribe intravenous penicillin to treat the mother's infection and prevent fetal infection. Gentamicin sulfate, which acts on gram-negative bacteria, would be inappropriate. Administering a corticosteroid, such as betamethasone, is inappropriate because the premature rupture of the membranes enhances fetal lung maturity. The lack of amniotic fluid causes early maturation of lung tissue. Cefaclor, which is available only in the oral form, is used for upper and lower respiratory tract infections and urinary tract infections by gram-negative staphylococci.

110. A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: 1. "Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers." 2. "Eating foods with moderate amounts of folic acid helps regulate blood glucose levels." 3. "Folic acid consumption helps with the absorption of iron during pregnancy." 4. "Folic acid is needed to

1. Folic acid supplementation is recommended to prevent neural tube defects and anemia in pregnancy. Deficiencies increase the risk of hemorrhage during birth as well as infection. The recommended dose prior to pregnancy is 400 mcg/day; while breast-feeding and during pregnancy, the recommended dosage is 400 to 800 mcg/day. Blood glucose levels are not regulated by the intake of folic acid. Vitamin C potentiates the absorption of iron and is also associated with blood clotting or collagen formation.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. The blood count is important, but the nurse should first assess patellar reflexes. The baseline weight is important, but the nurse should first assess patellar reflexes. The urinalysis should be obtained, but the nurse should first assess patellar reflexes. Preeclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the uri- nalysis. By assessing the patellar reflexes first, however, the nurse can make a pre- liminary assessment of the severity of the preeclampsia. For example, if the reflexes are 2, the client would be much less likely to become eclamptic than a client who has 4 reflexes with clonus.

A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which intervention would the nurse do first? 1. Check the status of the fetal heart rate. 2. Turn the client to her right side. 3. Test the leaking fluid with nitrazine paper. 4. Perform a sterile vaginal examination.

1. The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse's first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to her right side is not necessary. If the cord does prolapse, the client should be placed in a knee-to-chest or Trendelenburg position. Checking the fluid with nitrazine paper and vaginal examination are appropriate once the status of the fetus has been evaluated.

100. A 40-year-old client at 8 weeks' gestation has a 3-year-old child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling as genetic screening methods for the expected baby. The nurse is confident that the teaching has been understood when the client makes which statement? 1. "Each test identifies a different part of the infant's genetic makeup." 2. "Chorionic villus sampling can be performed earlier in pregnancy." 124 3. "The test results take the same length of time to be completed." 4. "Amniocentesis is a more dangerous procedure for the fetus."

2. Chorionic villus sampling (CVS) can be performed from approximately 8 to 12 weeks' gestation, while amniocentesis cannot be performed until between 11 weeks' gestation and the end of the pregnancy. Eleven weeks' gestation is the earliest possible time within the pregnancy to obtain a sufficient amount of amniotic fluid to sample. Because CVS take a piece of membrane surrounding the infant, this procedure can be completed earlier in the pregnancy. Amniocentesis and chorionic villus sampling identify the genetic makeup of the fetus in its entirety, rather than a portion of it. Laboratory analysis of chorionic villus sampling takes less time to complete. Both procedures place the fetus at risk, and postprocedure teaching asks the client to report the same complicating events (bleeding, cramping, fever, and fluid leakage from the vagina).

97. A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? 1. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. 2. Refer the client to her health care provider (HCP) for evaluation and treatment of the pain. 3. Discuss nutritional strategies to decrease the possibility of heartburn. 4. Support the client's use of acetaminophen to relieve pain.

2. The nurse seeing this client should refer her to a HCP for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Acetaminophen is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems.

After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client makes which statement? 1. "I may develop hyperthyroidism because of my high blood pressure." 2. "I need close monitoring because I may have a small-forgestational- age infant." 3. "It is possible that I will have excess amniotic fluid and may need a cesarean section." 4. "I may develop placenta accreta, so I need to keep my clinic appointments."

2. Women with chronic hypertension during pregnancy are at risk for complications such as preeclampsia (about 25%), abruptio placentae, and intrauterine growth retardation, resulting in a small-for-gestational-age infant. There is no association between chronic hypertension and hyperthyroidism. Pregnant women with chronic hypertension are not at an increased risk for hydramnios (polyhydramnios), an abnormally large amount of amniotic fluid. Clients with diabetes and multiple gestations are at risk for this condition. Placenta accreta, a rare placental abnormality, refers to a condition in which the placenta abnormally adheres to the uterine lining. It is not associated with chronic hypertension.

The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. What prescription would the nurse anticipate from the primary healthcare provider (HCP)? 1. frequent assessments of cervical dilation 2. intravenous oxytocin administration 3. vaginal cultures for Neisseria gonorrhoeae 4. sonogram for amniotic fluid volume index

3. Because an intrauterine infection may occur when membranes have ruptured, vaginal cultures for N. gonorrhoeae, group B streptococcus, and chlamydia are usually taken. Prophylactic antibiotics may be prescribed to reduce the risk of infection in the newborn. Frequent vaginal examinations should be avoided because they can further increase the client's risk for infection. Intravenous oxytocin to initiate labor may be used if an infection occurs. Bed rest can sometimes prolong the pregnancy and prevent a preterm birth. A sonogram may be used to validate rupture of the membranes with an amniotic fluid index. However, it is not needed if the HCP has confirmed the rupture.

At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (151.7 cm) has gained a total of 20 lb (9.1 kg), with a 1-lb (0.45-kg) gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which factor increases her risk for preeclampsia? 1. total weight gain 2. short stature 3. adolescent age group 4. trace proteinuria

3. Clients with increased risk for preeclampsia include primigravid clients younger than 20 years or older than 40 years, clients with 5 or more pregnancies, women of color, women with multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total weight gain of 20 lb (9.1 kg) at 32 weeks' gestation with a 1-lb (0.45-kg) weight gain in the last 2 weeks is within normal limits. Short stature is not associated with the development of preeclampsia. A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+ or more may be a symptom of pregnancy-induced - hypertension.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. To maintain safety for this client, the priority intervention is to: 1. maintain continuous fetal monitoring. 2. encourage family members to remain at bedside. 3. assess reflexes, clonus, visual disturbances, and headache. 4. monitor maternal liver studies every 4 hours.

3. The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised, and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system, but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

A woman has just been admitted to the emergency department subsequent to a head-on automobile accident. Her body appears to be uninjured. The nurse care- fully monitors the woman for which of the following complications of pregnancy? 1. Placenta previa.2. Transverse fetal lie. 3. Placental abruption. 4. Severe preeclampsia.

3. The fetus is well pro- tected within the uterine body. The mus- culature of the uterus and the amniotic fluid provide the baby with enough cush- ioning to withstand minor bumps and falls. A major automobile accident, how- ever, can cause anything from preterm premature rupture of the membranes, to a ruptured uterus, to placental abruption. The nurse should especially monitor the fetal heart beat for any variations.

A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 g/h. The nurse's assessment includes temperature 36.7°C; pulse 78; respirations 12/minute; B/P 128/82; urinary output 90 mL in last 4 hours via Foley catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats/min; cervix 4 cm dilated, 80% effaced, station −1. Which is the most appropriate action for the nurse to take? 1. Assess the Foley catheter for kinks in the drainage tubing, and obtain a urine sample. 2. Document findings, and continue to monitor her progress in labor. 3. Discontinue the magnesium sulfate infusion, and notify the healthcare provider (HCP). 4. Increase fluid intake intravenously, and measure intake and output.

3. The nurse must be alert to signs of magnesium sulfate toxicity that include loss of deep tendon reflexes, which is often the first sign (patellartendon response is the most common reflex tested); urinary output decreases (should have at least 30 mL/h); respirations decrease (12 respirations/min is low and could be developing respiratory distress). First action would be to stop magnesium sulfate infusion and notify the HCP . The Foley catheter tubing maybe kinked; however, looking at all findings would indicate the woman is experiencing magnesium sulfate toxicity. It is not a priority to obtain a urine sample. Documentation is extremely important to complete; however, the nurse must intervene by stopping the magnesium sulfate and notifying the primary care provider. Increasing fluid intake at this point is not appropriate with a woman who has magnesium sulfate toxicity. Intake and output should be ongoing for a client on intravenous fluids and magnesium sulfate and a diagnosis of preeclampsia.

2. A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include blood pressure, 140/90 mm Hg; pulse, 80 beats/min; respiratory rate, 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic? 1. headaches 2. blood glucose level 3. proteinuria 4. peripheral edema

3. The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The peripheral edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. While the preeclamptic client may have significant edema in the face and hands, edema can be caused by other factors and is not part of the diagnostic criteria. Headaches are significant in pregnancy-induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis.

A woman with asthma controlled through the consistent use of medication is now pregnant for the first time. Which client statement concerning asthma during pregnancy indicates the need for further instruction? 1. "I need to continue taking my asthma medication as prescribed." 2. "It is my goal to prevent or limit asthma attacks." 3. "During an asthma attack, oxygen needs to continue to be high for mother and fetus." 4. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

4. Asthma medications and bronchodilators should be continued during pregnancy as prescribed before the pregnancy began. The medications do not cause harm to the mother or fetus. Regular use of asthma medication will usually prevent asthma attacks. Prevention and limitation of an asthma attack is the goal of care for a client who is or is not pregnant and is the appropriate care strategy. During an asthma attack, oxygen needs continue as with any pregnant client, but the airways are edematous, decreasing perfusion. Asthma exacerbations during pregnancy may occur as a result of infrequent use of medication rather than as a result of the pregnancy.

A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching? 1. "It is permissible to douche if the fluid irritates my vaginal area." 2. "I can take either a tub bath or a shower when I feel like it." 3. "I should limit my fluid intake to less than 1 quart (0.95 L) daily." 4. "I should contact the healthcare provider if my temperature is 100.4°F (38°C) or higher."

4. Because of the client's increased risk for infection, successful teaching is indicated when the client states that she will contact the primary care provider if her temperature is 100.4°F (38°C) or greater. The client should be instructed to monitor her temperature twice daily. The client should refrain from coitus, douching, and tub bathing, which can increase the potential for infection. Showering is permitted because water in the shower does not enter the vagina and increase the risk of infection. A fluid intake of at least 2 L daily is recommended to prevent potential urinary tract infection.

105. Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition? 1. development of a future Rh-positive fetus 2. an antibody response to Rh-negative blood 3. a future pregnancy resulting in abortion 4. development of Rh-positive antibodies

4. Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rhpositive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative mothers do not develop sensitivities if the fetus is also Rh negative.

At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean birth. The nurse explains to the client that birth helps to prevent which complication? 1. Neonatal hyperbilirubinemia 2. Congenital anomalies 3. Perinatal asphyxia 4. Stillbirth

4. Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean section is necessary. Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia.

A nurse is completing a prenatal assessment on a woman who is 28 weeks' pregnant with gestational hypertension. Which findings should be reported to the primary care provider? Select all that apply. 1. dull headache 2. edematous feet 3. blurred vision 4. 1+ urine protein 5. fundal height of 28 cm

1,3,4. The nurse must be alert for any signs and symptoms of superimposed preeclampsia in women with gestational hypertension. Dull headache, blurred vision, and protein in urine are all classic signs of preeclampsia in pregnancy and must be reported to the primary care provider immediately. Edema in lower extremities is not a sign of preeclampsia in pregnancy as it is seen in uncomplicated pregnancy. Fundal height of 28 cm is an expected finding.

A client who is 34 weeks pregnant is admitted to the labor and birth room with the diagnosis of preeclampsia. The client's vital signs are as follows: blood pressure 149/92 mm Hg; pulse, 62 beats/min; respiratory rate, 18 breaths/min; temperature, 98.4°F (36.8°C). What is the priority intervention? 1. Encourage the client to lie in a lateral position. 2. Administer an antihypertensive agent. 3. Notify the healthcare provider (HCP) of the client's blood pressure. 4. Check the cervix.

1. Although the client is being admitted, the first response would be to attempt to lower BP by putting the client in left lateral position. The other interventions may be appropriate later, but left lateral position would be the priority.

A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which interventions? Select all that apply. 1. hepatitis B immune globulin at birth 2. series of three hepatitis B vaccinations per recommended schedule 3. hepatitis B screening when born 4. isolation of infant during hospitalization 5. universal precautions for mother and infant 6. contraindication for breast-feeding

1,2,5. The test result indicates that the mother has an active hepatitis infection and is a carrier. Hepatitis B immune globulin at birth provides the infant with passive immunity against hepatitis B and serves as a prophylactic treatment. Additionally, the infant will be started on the vaccine series of three injections. The infant should not be screened or isolated because the infant is already hepatitis B positive. As with all clients, universal precautions should be used and are sufficient to prevent transmission of the virus. Women who are positive for hepatitis B surface antigen are able to breast-feed.

A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What actions are indicated by the nurse at this time? Select all that apply. 1. Reassure the client that headaches are a normal part of pregnancy. 2. Assess the client for vision changes or epigastric pain. 3. Obtain a nonstress test. 4. Assess the client's reflexes and presence of clonus. 5. Determine if the client has a documented ultrasound for this pregnancy.

2,3,4. Headaches could be a sign of preeclampsia/eclampsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyper reflexes, and the presence of clonus. Her fetus should be assessed using a nonstress test. An ultrasound done in this pregnancy does not give information to assess the presence of preeclampsia/eclampsia.

A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as showing which fetal heart rate pattern? 1. frequent late decelerations 2. decreased fetal movement 3. inconsistent late decelerations 4. lack of fetal movement

3. A contraction stress test is used to evaluate fetal well-being during a simulated labor. A suspicious contraction stress test indicates inconsistent late deceleration patterns requiring further evaluation. A negative contraction stress test indicates no late decelerations and is the desired outcome. A positive contraction stress test indicates fetal compromise with frequent late decelerations. Fetal movements are one of the parameters of a biophysical profile and are detected with nonstress testing. Decreased or absent fetal movements may indicate central nervous system dysfunction or prematurity. Lack of fetal movement or decreased fetal movement is not associated with contraction stress testing.

Which action should the nurse take first when admitting a multigravid client at 36 weeks' gestation with a probable diagnosis of abruptio placentae? 1. Prepare the client for a vaginal examination. 2. Obtain a brief history from the client. 3. Insert a large-gauge intravenous catheter. 4. Prepare the client for an ultrasound scan.

3. Abruptio placentae is a medical emergency because the degree of hypovolemic shock may be out of proportion to visible blood loss. On admission, the nurse should plan to first insert a large-gauge intravenous catheter for fluid replacement and oxygen by mask to decrease fetal anoxia. Vaginal examination usually is not performed on pregnant clients who are experiencing third-trimester bleeding due to abruptio placentae because it can result in damage to the placenta and further fetal anoxia. The client's history can be obtained once the client has been admitted and the intravenous line has been started. The goal is birth of the fetus, usually by emergency cesarean section. The nurse should also plan to monitor the client's vital signs and the fetal heart rate. Ultrasound is of limited use in the diagnosis of abruptio placentae.

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week gravid client to call the office if she experiences which of the following? 1. Headache and decreased output.2. Puffy feet.3. Hemorrhoids and vaginal discharge. 4. Backache.

1. It is important for the test taker to realize that, although some symptoms like puffy feet may seem sig- nificant, they are normal in pregnancy, while other symptoms like headache, which in a nonpregnant woman would be considered benign, may be potentially very important in a pregnant woman.

A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. The client's blood pressure is 164/110 mm Hg. Which finding would alert the nurse that the client may be about to experience a seizure? 1. decreased contraction intensity 2. decreased temperature 3. epigastric pain 4. hyporeflexia

3. Epigastric pain or acute right upper quadrant pain is associated with the development of eclampsia and an impending seizure; this is thought to be related to liver ischemia. Decreased contraction intensity is unrelated to the severity of the preeclampsia. Typically, the client's temperature increases because of increased cerebral pressure. A decrease in temperature is unrelated to an impending seizure. Hyporeflexia is not associated with an impending seizure. Typically, the client would exhibit hyperreflexia.

The nurse is caring for a client who was just admitted to the hospital to rule out ec- topic pregnancy. Which of the following orders is the most important for the nurse to perform? 1. Assess the client's temperature.2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture.4. Report complaints of dizziness or weakness.

4. The nurse must priori- tize care. When the question asks the test taker to decide which action is most important, all four possible responses are plausible actions. The test taker must determine which is the one action that cannot be delayed. In this situation, the most important action for the nurse to perform is to report complaints of dizzi- ness or weakness. These symptoms are seen when clients develop hypovolemia from internal bleeding.

When counseling a preeclamptic client about her diet, what should the nurse en- courage the woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars.

Clients with preeclamp- sia are losing albumin through their urine. They should eat a well-balanced diet with sufficient protein to replace the lost protein. Even though preeclamptic clients are hypertensive, it is not recom- mended that they restrict salt—they should have a normal salt intake— because during pregnancy the kidney is salt sparing. When salt is restricted, the kidneys become stressed.

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate? 1. decreased generalized edema within 8 hours 2. decreased urinary output during the first 24 hours 3. sedation and decreased reflex excitability within 48 hours 4. absence of any seizure activity during the first 48 hours

4. The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe birth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

hich finding should the nurse expect when assessing a client with placenta previa? 1. Severe occipital headache.2. History of renal disease.3. Previous premature delivery. 4. Painless vaginal bleeding.

4. There are three differ- ent forms of placenta previa: low-lying placenta—one that lies adjacent to, but not over, the internal cervical os; partial—one that partially covers the internal cervical os; and complete—a placenta that completely covers the in- ternal cervical os. There is no way to deliver a live baby vaginally when a client has a complete previa, although there are cases when live babies have been deliv- ered when the clients had low-lying or partial previas.

A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the fol- lowing signs/symptoms is characteristic of this diagnosis? 1. Dark brown rectal bleeding. 2. Severe nausea and vomiting. 3. Sharp unilateral pain.4. Marked hyperthermia.

The most common lo- cation for an ectopic pregnancy to im- plant is in a fallopian tube. Because the tubes are nonelastic, when the pregnancy becomes too big, the tube ruptures. Uni- lateral pain can develop because only one tube is being affected by the condition. In addition, some women complain of generalized abdominal pain.

After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which problem? 1. hydrocephalic infant 2. abruptio placentae 3. intrauterine growth restriction 4. poor placental perfusion

1. Congenital anomalies such as hydrocephalus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth restriction, and poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of severe vasoconstriction. Intrauterine growth restriction is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction.

A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appro- priate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure.3. Assess the woman's fundal height.4. Ask the woman about stressors at work.

2. Headache is a symptom of preeclampsia. Preeclampsia, a serious complication, is a hypertensive disease of pregnancy. In order to determine whether or not the client is preeclamptic, the next action by the nurse would be to assess the woman's blood pressure.

A client, G2P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? 1. "When did you have your pregnancy test done?"2. "When was the first day of your last menstrual period?"3. "Did you have any complications with your first pregnancy?" 4. "How old were you when you first got your period?"

2. The date of the last menstrual period is important for the nurse to know. Ectopic pregnancies are usually diagnosed between the 8th and the 9th week of gestation because, at that gestational age, the conceptus has reached a size that is too large for the fallopian tube to hold.

Following an eclamptic seizure, the nurse should assess the client for which complication? 1. polyuria 2. facial flushing 3. hypotension 4. uterine contractions

4. After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools.4. Epigastric pain.

4. When the liver is de- prived of sufficient blood supply, as can occur with severe preeclampsia, the or- gan becomes ischemic. The client expe- riences pain at the site of the liver as a result of the hypoxia in the liver.